The Impact of a Large-Scale Social and Behavior Change Communication Intervention in the Lake Zone Region of Tanzania on Knowledge, Attitudes, and Practices Related to Stunting Prevention

Background: Large-scale social and behavioral change communication (SBCC) approaches can be beneficial to achieve improvements in knowledge, attitudes, and practices (KAP). Addressing Stunting in Tanzania Early (ASTUTE) included a significant SBCC component and targeted precursors to stunting including KAP related to maternal and child health, antenatal care, WASH, childhood development, and male involvement. METHODS: Baseline, midline, and endline surveys were conducted for a total of 14,996 female caregivers and 6726 male heads of household in the Lake Zone region of Tanzania. Regression analyses were used to estimate differences in KAP from baseline to midline and endline. Results: Women’s knowledge of handwashing and infant/child feeding practices, and attitudes related to male involvement, consistently improved from baseline to midline and baseline to endline. Women’s practices related to antenatal care, breastfeeding, and early child development improved from baseline to midline and baseline to endline. Improvements in KAP among male heads of household were varied across indicators with consistent improvement in practices related to child feeding practices from baseline to midline and baseline to endline. Conclusion: Many changes in KAP were observed from baseline to midline and baseline to endline and corresponded with SBCC programming in the region. These results provide support for the value of large SBCC interventions. Public health efforts in settings such as Tanzania may benefit from adopting these approaches.


Introduction
Tanzania has achieved dramatic improvements in maternal and child health in recent decades, yet undernutrition remains a serious public health problem [1]. Despite the Tanzanian government providing free, universal maternal, newborn, and child health (MNCH) services, women's dietary practices and nutritional status are far from ideal. In Tanzania, challenges include an uneven commitment to women's nutrition, limited human resources, and a lack of exposure to innovative social and behavioral change communication (SBCC) strategies to improve nutrition practices [2]. SBCC interventions are designed to address social and behavioral issues generally [3] and have been widely implemented for childhood nutrition and stunting prevention purposes specifically [4][5][6][7]. SBCC interventions may be inclusive of multiple methods including mass communication, interpersonal communication, group-based approaches, advocacy, community or social mobilization, and capacity strengthening [8]. Recent systematic reviews and meta-analyses of SBCC approaches to

Materials and Methods
UKaid and the Foreign, Commonwealth and Development Office (FCDO) provided funding to IMA World Health for the implementation of ASTUTE. A consistent tagline was used at the end of each theory-based radio spot, which was broadcast a total of 70,000 times. TV spots were aired before and during the evening news on national and regional stations a total of 1198 times. CHWs used a problem-based negotiated behavior change approach during in-home visits to implement IPC components of the intervention. They counseled mothers and referred children with growth faltering to health facilities for treatment and counseling. They also encouraged both mothers and male partners to engage in stimulation activities (e.g., drawing, playing, playing, naming objects, or talking with them) for their children by providing education and support.

Sample
Data came from three distinct cross-sectional surveys completed by a unique subsample of participants during each data collection period between 2016 and 2020. Surveys were conducted in five regions of Tanzania's Lake Zone region, namely Geita, Kagera, Kigoma, Mwanza, and Shinyanga. A stratified, multi-stage random sample design was used to select survey participants. Eligibility to participate was limited to households with a child under two years of age. Participants were randomly sampled from 243 villages that were selected from among the five participating regions. The baseline survey was carried out in 2016, prior to the launch of ASTUTE programming. A total of 5000 mothers, hereafter known as female caregivers, and 1144 corresponding fathers, hereafter known as male heads of household, were surveyed. The midline survey was conducted in 2019 and included 5000 female caregivers and 2502 male heads of households. The endline survey was conducted in 2020 after all ASTUTE programming ended and included 4996 female caregivers and 3080 male heads of household. The present study sample includes all baseline, midline, and endline participants for a total of 14,996 female caregivers and 6726 male heads of household. Participant demographics are presented in Table 1.

Study Design and Procedure
The female caregiver of the youngest child in the home responded to questionnaire items. The male head of household was asked to respond only if available and applicable. IPSOS, a local research firm, collected all three waves of data. They comprised a field team with 50 enumerators and 10 supervisors. Twenty-five percent of records were qualitychecked using revisits and phone checks. DMI's internal IRB and Tanzania's National Institute for Medical Research (TZ: NIMR/HQ/R.8a/Vol.IX/2344) provided Institutional Review Board (IRB) approval. Informed consent was collected before the surveys began and participants were reminded that participation was voluntary and they could stop the survey at any time. Questionnaire items were written in English, translated into Kiswahili, and then back-translated to English to ensure the original meaning was retained. The questionnaires were piloted, modified, and finalized before being administered to participants. Interviews were conducted in the participants' homes and lasted on average 50-60 min. Baseline data were collected using hard copies and midline and endline data were recorded using smartphones and PDAs (personal digital assistants).

Measures
Participants' demographic characteristics were measured and collected. Exposure to the various components of the intervention (radio, TV, and IPC intervention in the midline and endline questionnaires) were also collected along with key MNCH indicators.
Wealth. A calculated composite variable adapted from a previously validated index was used to estimate household wealth [19]. Two sub-indices comprised the index. The first sub-index represented access to services and ownership of consumer durables was the second. Items pertaining to access to services included the availability of safe drinking water sources (e.g., protected wells, a public standpipe) and safe sanitation (e.g., a flush toilet). Pit latrines were not considered safe sanitation for this study. Seven items were measured to represent consumer durables. These included ownership of a radio, TV, bicycle, motorcycle, mobile phone, boat, or animal-drawn cart. Each index was calculated by summing the total of the indicators within each index. An average of the two indices was then used to calculate an overall wealth score, with possible values ranging between 0 and 1. Higher wealth scores indicate higher socioeconomic status. Housing quality was not included in this index as the data were not available.
Intervention Exposure. Only data collected at endline were used to measure exposure to the intervention. Exposure was estimated separately for each of the radio, TV, and IPC intervention components. Exposure to the radio component was coded 'yes' if respondents reported affirmatively to having heard the example spot(s) that concluded with the sound of a laughing baby or if they reported having heard radio messages that advised about maternal and child health and/or child development. Exposure to TV was coded 'yes' if respondents reported affirmatively to having seen the example image frame(s) on TV or 'reported seeing messages on the TV that advised about maternal/child health/child development'. IPC exposure was coded 'yes' if respondents reported affirmatively that a (community) health worker had visited their home and advised them about maternal and child health and/or child development. Exposure to each intervention component (radio, TV, and IPC) was measured for female caregivers. IPC mostly targeted female caregivers, so male head of household respondents were only asked questions about exposure to radio and TV.

Analysis
Data were deidentified and shared only with study personnel to ensure confidentiality. STATA version 16 (College Station, TX, USA) was used to clean and recode variables in each of the three datasets. SAS 9.4 (Cary, NC, USA) was used to conduct analyses. Basic frequency statistics were calculated for key demographic variables. Logistic regression analysis was used to identify changes in KAP at each time point, comparing the midline and endline values to the baseline values. All models were adjusted for respondent age, education, and household wealth.

Demographics
Most female caregivers at each round were 20-29 years of age, able to read, had completed primary school, were crop farmers, and were monogamous (Table 1). Kiswahili and Sukuma were the most spoken languages. Almost half (46%) of female caregivers reported hearing mass media messages only regarding the intervention, while 14 percent heard both mass media messages and received IPC, 6 percent received IPC only, and 34 percent had no reported exposure to the intervention ( Table 2).

Knowledge and Attitudes
Women's knowledge about when to begin giving complementary foods (foods and liquids in addition to breastmilk) and critical handwashing moments improved significantly from baseline to midline and baseline to endline (Table 3). While knowledge levels increased slightly from baseline to midline and baseline to endline for early initiation of breastfeeding and exclusive breastfeeding for the first six months of life, increases were not statistically significant. Understanding that handwashing without soap does not clean hands properly increased significantly from baseline to midline but the increase from baseline to endline was not significant.  1 Chores including fetching water, farming, or 'something else so that you could rest'. 2 Times included: After latrine use; after assisting a child who has defecated; before preparing food; before eating; before feeding a child; after cleaning the compound; after contact with animal feces. 3 Within the first hour.

Practices
Female caregivers reported eating significantly more types of food, attending more antenatal visits, having a partner help with chores during the most recent pregnancy, singing more to the child, and drawing more with the child from baseline to midline and baseline to endline (Table 4). Female caregivers were significantly more likely to report emptying both breasts when breastfeeding, counting in front of the child more, and engaging in more activities with the child from baseline to endline, but not from baseline to midline. Inversely, female caregivers increased breastfeeding in the first hour of life from baseline to midline but not from baseline to endline.
Male heads of household were significantly more likely to feed the youngest child in the previous three months from baseline to midline than from baseline to endline (Table 5). Male heads of household were significantly more likely to point out objects to the child and talk to and play with the child from baseline to endline but not from baseline to midline. There were significantly more male heads of household who reported helping their wives with chores during a previous pregnancy from baseline to midline but not from baseline to endline.

Discussion
The purpose of this study was to determine whether MNCH indicators of KAP improved from baseline to midline and baseline to endline. While not all changes were significant, and not all changes were consistent at the different data collection periods, the results were positive overall. Both midline and endline results for 26 indicators were compared to baseline, for a total of 52 comparisons. Of these 52 comparisons, 33 (63%) demonstrated statistically significant improvement. For female caregivers, improvement in both knowledge and attitudes was less impressive than improvements among practices indicators. For example, of the eight knowledge and attitudes indicators, four (50%) showed significant improvement at the midline compared to the baseline, and four (50%) significantly improved at the endline compared to the baseline. It should be noted that three indicators showed significant improvement at both the midline and endline compared to baseline, while one indicator was significant at the midline only and one significant at the endline only when compared to baseline. More importantly, of the 12 practices indicators measured for female caregivers, nine (75%) significantly improved by midline, and 10 (83%) significantly improved by endline when compared to baseline. As with the knowledge and attitude indicators, the majority of practice indicators improved in comparison to baseline at both midline and endline, yet one indicator showed significant improvement only at the midline while two showed significant improvement only at the endline when compared to baseline. Knowledge about exclusive breastfeeding and the introduction of foods and liquids, while similar, appear to be interpreted differently among respondents. Evidence of this is that nearly 92 percent of respondents at baseline were already knowledgeable about exclusive breastfeeding, while only 72 percent were knowledgeable about when to introduce foods and liquids into a child's diet. Among the five practices measured for male heads of household, three (60%) had significantly improved by midline and three (60%) had significantly improved by endline when compared to baseline. As with measures for female caregivers, significant improvements among male heads of household were not consistent across data collection periods. Other studies of large-scale healthrelated campaigns in low-and middle-income countries have reported similar encouraging results [20][21][22]. The purpose of these campaigns is to share information about optimal health behaviors, improve attitudes, and get large numbers of individuals to adopt these behaviors [23]. Well-implemented media campaigns have been shown to change social norms and behaviors in positive ways [23][24][25][26].
The current study's findings are especially impressive given the difficulty in promoting behavior change and improving health practices. While there were fewer improvements in knowledge and attitudes, it is important to note that efforts to increase knowledge and attitudes are undertaken solely with the express desire to improve practices.
Ideally, there would be consistent and linear improvement in the practice of all targeted behaviors over time when comparing midline and endline data to baseline data. Including the same participants at each data collection period, as opposed to surveying a unique sample of participants at each period as this study did, may have yielded more consistent results. Variations in the improvement of different indicators at different time periods in this study are consistent, however, with other SBCC programming [6]. In their review of SBCC programming's impact on specific nutrition-related indicators, Kennedy et al. note that varying levels of success among indicators are common when evaluating large-scale SBCC interventions [6]. Evaluation of SBCC interventions is impeded by the challenge of measuring and determining the dose and response to various program interventions. Kennedy et al. indicate that combining individuals with various levels of exposure to interventions is a common practice hindering analyses of SBCC [6]. Indeed, the current study did not attempt to correlate SBCC exposure to study indicators nor did it quantify an individual participant's exposure (dose) to mass media or IPC programming with respect to KAP surrounding MNCH (response), rather it addressed the combined impact of SBCC programming on the population represented by a large, randomly selected cohort at midline and endline compared with a similar cohort at baseline. For these reasons, the current study's level of variation in results among variables and between time periods may be expected.
Several significant improvements in knowledge and attitudes were related to male involvement. For example, female caregivers reported that male involvement with household chores during pregnancy increased at both midline and endline compared to baseline. Female caregivers also reported that men would approve of other men helping in this way. Similarly, male heads of household perceived that most men in the community helped wives with household chores during pregnancy at midline compared to baseline. These shifts in knowledge and attitudes are especially promising if they are indicative of shifting societal and gender norms leading to greater equity in gender relations through male involvement in household and parenting duties [27].
It is noteworthy that those knowledge and attitudes indicators which did not show significant improvements from baseline to midline or baseline to endline were generally already very high at baseline (i.e., Agree child should only be given breastmilk for first 6 months; and How soon after birth should a child be put to the breast?) rendering any additional significant improvements in the population statistically challenging. For example, in their analysis of endline-only ASTUTE data, Beckstead et al. [9] found significant associations between exposure to SBCC radio programming and a variety of IYCF practices as well as significant associations between SBCC television programming and IYCF knowledge. Significant findings between SBCC exposure and enline data from Beckstead et al. may be helpful in gauging the impact of SBCC programming on indicators that are high at each of the three data collection periods in the current study.
Improvements in practices were impressive, especially among female caregivers. Only three practices indicators did not show significant improvement from baseline to midline (i.e., Usually empty both breasts when breastfeeding; Count in front of child last week; and Mean number of activities engaged with child in last week), and only two practices indicators did not show significant improvement from baseline to endline (i.e., Initiated breastfeeding in first hour and Mean number of activities engaged with child in last week).
There were significant improvements in ECD-related KAP in the current study. The current study's findings might be compared with the cross-sectional analysis of endline-only data by Broadbent et al. [11] who identified a significant association between exposure to SBCC mass media programming and ECD behaviors. Early childhood development and cognitive stimulation are vital to the child's well-being and have been found to impact both physiological [28] and neural development [29]. For example, an investigation of parental involvement and ECD in Tanzania concluded that higher levels of parental stimulation re-sulted in improved child cognition, language, and motor skills [30]. As a stunting prevention approach, ECD has been found to be equally important as traditional nutritional and dietary indicators [31,32]. SBCC appears to be an effective approach for increasing female caregiver ECD as measured by singing to a child and drawing with a child in particular.
Improvements in practices indicators of male heads of household were modest, with "Man helped feed child frequently in past three months" showing significant improvement compared to baseline at both midline and endline. Other indicators only saw significant improvements between baseline and midline (i.e., Male helped wife with chores during pregnancy) or baseline to endline (i.e., Man points out objects to child; and Male caregiver talked to the child and played with the child in the last week). "Man purchased food for child in past month" did not significantly improve at either midline or endline when compared to baseline. While only modest differences in positive directions were observed, these findings can be interpreted as progress given the challenge of increasing male involvement generally and increasing male participation in promoting early childhood development specifically. Predominant and prevailing sociocultural norms work to discourage male involvement in pregnancy and child-rearing practices [33]. Extensive literature has documented the challenge of overcoming lingering cultural beliefs that childcare is the role of women only and that the role of men is to provide financially for the family [34][35][36][37]. Well-intended public health interventions have perhaps indirectly and unintentionally reinforced such norms through programming focused exclusively on mothers at the exclusion of fathers [35,[38][39][40].
It is worth reiterating that the current study found comparatively fewer improvements in knowledge and attitude indicators as compared to practices indicators. Altering behavior is generally more challenging than increasing knowledge or shifting existing attitudes toward increasing care or concern for specific health behaviors or practices. Indeed, SBCC programs often measure shifts in knowledge and attitudes as a proxy for the more difficult to influence and measure practices. Future research should continue to explore the complex and weaker-than-expected association between an individual's knowledge and his or her behavioral practices [41,42].

Limitations
Evaluating large-scale SBCCs can be challenging for a variety of reasons and the current study's findings should be considered in light of several limitations. Levels of exposure to SBCC programming were reported (Table 2) to show the reach of this programming, but the current study did not attempt to correlate SBCC exposure to study indicators. When a region is flooded with health promotion messaging, calculating both direct or indirect exposure and measuring the dose or duration of said exposure to that messaging is difficult and often beyond the scope of program planners, implementers, and researchers. For example, household discussions between one family member exposed to SBCC programming and another without exposure may extend the program's reach. Such indirect exposure is key to the success of SBCC approaches while paradoxically increasing the challenge of program evaluation. Additionally, the measurement of several study indicators was impacted by unusually high scores at baseline. Finally, given that the ASTUTE program was implemented in only five regions, other regions are not represented. Despite these limitations, this study suggests a pattern of improvements in KAP after ASTUTE began. These conclusions are based on rigorous methods, a large sample size, and strict data collection regimens across three sampling periods. Findings are supportive of future SBCC interventions, especially programming targeting knowledge and attitudes related to male involvement and IYCF together with practices related to ANC, ECD, and male involvement. Additional research is needed to better understand how large-scale communication campaigns can be improved and integrated into other health promotion efforts and interventions. Further investigation is likewise needed in understanding why some indicators examined in this study remain resistant to SBCC messaging. Identifying SBCC approaches capable of effectively promoting ECD among male heads of household is of prime importance. Promoting the benefits of breastfeeding practices and a woman's reduced workload during pregnancy are examples of two other important practices in need of continued attention.

Conclusions
This study examined KAP related to standard MNCH indicators before, during, and after a large-scale SBCC program designed to address the persistent challenge of childhood stunting in Tanzania. Data analyzed compared a large sample of participants at baseline with similarly sized samples at both midline and endline. Study results support the use of SBCC programming for improving KAP generally. SBCC programming appears particularly effective at influencing the knowledge and attitudes of female caregivers related to male involvement and IYCF. SBCC approaches are similarly effective in promoting practices associated with ANC, ECD, and male involvement. Female caregiver knowledge of breastfeeding timing together with attitudes related to women doing chores appear to be resistant to SBCC programming. These findings can help to inform future SBCC interventions targeting key indicators associated with stunting prevention.